The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

The nurse waits 5 minutes between administering prescribed eye drops.

The nurse leaves the eye shield in place while the client sleeps.

The nurse is instructing the client not to drive at night.

The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.

Answer and Explanation

The Correct Answer is D

Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.

Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.

Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.

Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.

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Correct Answer is C

Explanation

Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.

Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.

Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.

Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.

A. Dilated pupils B. Hyperactive bowel sounds C. Hyperglycemia D. Positive Chvostek's sign

Correct Answer is D

Explanation

Choice A reason: Dilated pupils are not a clinical manifestation of hypocalcemia. Hypocalcemia primarily affects the neuromuscular system, leading to symptoms such as muscle cramps and tetany. Pupillary changes are not commonly associated with low calcium levels.

Choice B reason: Hyperactive bowel sounds are not typically associated with hypocalcemia. While hypocalcemia can lead to muscle spasms and cramps, it does not usually cause changes in gastrointestinal motility. Hyperactive bowel sounds may be related to other gastrointestinal disorders.

Choice C reason: Hyperglycemia is not a clinical manifestation of hypocalcemia. Hypocalcemia affects calcium levels in the blood and neuromuscular function. Hyperglycemia is related to elevated blood sugar levels and is not directly connected to calcium metabolism.

Choice D reason: Positive Chvostek's sign is a clinical manifestation of hypocalcemia. This sign is elicited by tapping on the facial nerve, causing twitching of the facial muscles. It is an indication of neuromuscular irritability due to low calcium levels.

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The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

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